Closures, Denials, Terminations, and Reductions of Services 525-05-40

(Revised 2/1/22 ML #3663)

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1. Closures

If a new or current recipient has not utilized services within a 30-day period of time, a citation to terminate the case may be requested (if appropriate) from the Program Administrator and an SFN 474 sent to Aging Services if the case is to be closed.

If the individual has not received services because a provider has not been secured, and the individual is still eligible and wants to continue pursuing a provider, the case must remain open. The case manager must make a quarterly contact with the individual. If the individual will incur a case management fee, they must be informed of this. The case manager is required to continue attempts in securing a provider. In doing so, they may need to staff the situation with Aging Services administrators and/or discuss strategies with the individual such as publishing an advertisement for service providers, etc.

If the services are expected to start or resume within 3 months, it is allowable for the case to remain open. This does not require approval from a Program Administrator. The purpose of this exception is to allow eligible individuals to resume services without having to complete the application process again.

• The reason for delay or pause in services must be documented in the individual’s file.
• The case manager must document how the need is met while the identified service needs are pending.
• The case manager must follow up monthly with the individual to provide support and assistance mitigating the issue causing the delay in service implementation.
• If the services do not resume or start within 3 months, approved must be received from the Program Administrator to keep the case open OR the case manager must request a termination to close the case and submit an SFN 474 to Aging Services/HCBS.

If a current recipient enters a skilled nursing facility or swingbed, and it is anticipated that the length of stay will be 3 months or less, it is allowable for the case to remain open. This does not require approval from a Program Administrator.

Any time a Medicaid waiver recipient enters a skilled nursing facility (regardless of if the case remains open or is closed), an SFN 474 must be submitted to HCBS/Aging Services to close out the HCBS LOC screening even if the Medicaid waiver case is to remain open. This is for the purposes of billing, as overlapping screenings in MMIS can interfere with payment. It is acceptable for the Medicaid waiver LOC to close on the same day as the skilled nursing facility LOC opens. Example: if an individual is admitted to a skilled nursing facility on 11/2, the Medicaid Waiver LOC can close 11/2. If a Medicaid waiver LOC is to close, but the case is to remain open, the case manager must indicate this on the SFN 474. If/when Medicaid waiver services resume, an SFN 474 must be submitted to re-open the HCBS LOC screening unless a new HCBS LOC screening is due and completed by the case manager.

HCBS Case Managers must notify HCBS Program Administration of HCBS closures using the SFN 474, this includes all HCBS programs. The Notification is to be submitted to HCBS/Aging Services within 3 days of closing the case.

10-day Notice Not Required

Either because the individual has taken action that results in the termination of services (i.e. an individual indicating, in writing, their desire to terminate services; moving out of the area, admitted to a nursing facility, etc.) or it is a change in benefits that is not appealable, a 10-day notice is not required and an HCBS Notice of Reduction, Denial, or Termination (SFN 1647) is not required.  The HCBS Case Manager is required to inform the individual of the action taken to close their case.  The notice may be a letter stating the effective date of the closure and the specific reason.  Furthermore, if an individual chooses to reduce their service(s) and they indicate this request in writing, an SFN 1647 HCBS Notice of Reduction, Denial, or Termination with the 10-day notice is not required. The reduction may become effective upon receipt of the individual’s signed statement and new signed care plan. Note that any reduction not requiring an SFN 1647 HCBS Notice of Reduction, Denial, or Termination must be at the individual’s request and not a result of programmatic guidelines. While the individual has the right to reduce their services any time, they also have the right to a 10-day notice/SFN 1647 outlying their appeal rights if the reduction is a result of programmatic guidelines.

• Example: An individual prefers to have just two baths a week instead of the three that are authorized. They can sign a statement requesting the units for this task are reduced, and would then sign a new care plan reflecting that reduction. The case manager must keep the signed statement in the file.
  
  
• Example: During an assessment,it is determined that an individual now requires less time for the QSP to assist them in completing their maintenance exercises. This is evidenced by the physical therapist’s instructions outlining the required technique and frequency. An SFN 1647 HCBS Notice of Reduction, Denial, or Termination must be issued, as the reduction is based on programmatic guidelines.

Note:  If the case closure is due to death and the HCBS Case Manager has factual information confirming the individual’s death, a letter is not required to be forwarded to the individual's estate.  The source of the information should be documented in the case file.

Any of the reasons below do not require a 10-day notice:

1. HCBS Case Manager has factual information confirming the death of the individual.
   
   
2. The HCBS Case Manager has received in writing the individual’s decision to terminate or reduce services.
   
   
3. Individual has been admitted to a basic care facility, nursing facility, or PACE.
   
   
4. Individual's whereabouts are unknown.
   
   
5. For specific time limited services (Examples such as: Chore Labor, Chore Snow Removal, ERS installation).
   
   
6. State or federal government initiates a mass change which uniformly and similarly affects all similarly situated applicants, recipients, and households.
   
   
7. Determined the individual has moved from the area.

2. Reduction/Denial/Termination Notice

The applicant/recipient must be informed in writing of the reason(s) for the denial/termination/reduction. The HCBS case manager completes the SFN 1647, or if allowable, sends a letter with all applicable information to the applicant/recipient or their legal decision maker. The citation used to complete the SFN 1647 must be obtained from a HCBS Program Administrator.

• Reduction in services may include reducing the number of units or reducing the tasks in a specific category. An SFN 1647 HCBS Notice of Reduction, Denial, or Termination and a 10-day notice is required unless the recipient is requesting the reduction and has signed a statement stating such. (the recipient agreeing with the reduction is not sufficient, as the reduction must stem from the recipient's request).
  
  
• Termination of a service is discontinuing the service. The individual must be informed in writing of the termination by the case manager providing them with a completed SFN 1647, or the individual may provide a written statement indicating they no longer want the service.
  
  
• Denial of a service may include denying a service to a new applicant or current recipient denying the number of units a new applicant or current recipient requests. If a new applicant or current recipient requests a service, it is not sufficient for the case manager to simply inform them that it is not part of the service array or that it will not be approved. The case manager must contact the Program Administrator for a denial citation, or make a formal request for an approval exception or reasonable accommodation.

• When denying units or services the individual has requested, the individual must be informed in writing of the denial by providing them with a completed SFN 1647.
  
  
• When a home visit is completed to assess an applicant for services, an application for service is implied by the individual, and a completed SFN 1647 must be provided informing the individual of the denial, or the individual can provide a written statement indicating they do not want the service. If a home visit is completed but an assessment wasn’t completed, but information was shared, an SFN 1647 is not required.
  
  
• When an individual contacts the HCBS Case Manager for general information about the service, the individual applicant must be made aware that a formal determination of eligibility for the service cannot be made without completing a home visit and assessment. The individual must be offered the option of an assessment.

• After a formal assessment is completed, the individual must be informed in writing of the denial by providing them with a completed SFN 1647, or the individual may provide a written statement indicating they do not want the service.

The Notice of Denial/Termination/Reduction is dated the date of mailing.  Contact the HCBS Program Administrator to obtain the legal reference required at "as set forth . . ." The legal reference must be based on federal law, state law and/or administrative code; reliance on policy and procedures manual reference is not sufficient.

When an individual is no longer eligible for the HCBS funding, the HCBS Case Manager must terminate services under this funding source.  Even if services continue under another funding source, the individual must be informed in writing of the reasons they are no longer eligible under this Service Chapter.

The individual must be notified in writing by completing a SFN 1647 at least 10 days (it may be more) prior to the date of terminating servicesUNLESS it is for one of the reasons stated in this section. The date entered on the line, the effective date field, is 10 calendar days from the date of mailing the Notice or the next working day if it is a Saturday, Sunday, or legal holiday.

The HCBS Case Manager may send a cover letter with the SFN 1647 identifying other public and/or private service providers or agencies that may be able to meet the denied/terminated applicant/recipient's needs.

3. Former SPED, ExSPED, or Medicaid waiver Recipients

SPED, ExSPED, or Medicaid waiver: if HCBS recipient closed due to admission to a skilled nursing facility or swing bed, and re-opens services within 3 months:

For Medicaid waiver, SPED, and Expanded SPED:

• A new Application for Service (SFN 1047) does not need to be completed.

For Medicaid waiver:

• A new Explanation of Client Choice (SFN 1597) does not need to be completed.

For SPED:

• A new SPED financial assessment (SFN 820) does not need to be completed unless there has been a substantial financial change, or the individual is due for a required annual assessment.

For SPED or ExSPED:

• An SFN 1820 or SFN 56 does not need to be completed.

• An SFN 676 does need to be completed and submitted to HCBS/Aging Services. If all information is the same, it is allowable to use the previously approved SFN 676 and simply indicate the date the individual is to re-open in the field “Date of Application” and select “Re-Open” in the “Application Type” field.

SPED or ExSPED: if HCBS recipient closed for any reason, and re-opens services within 60 days:

A former SPED or Expanded SPED Program recipient can be reinstated without going through the SPED or Expanded SPED Program Pool if services are re-established within 60 days from the date of closure. However, the HCBS Case Manager must determine that the former service recipient is still eligible and what the current service needs are.

If an individual will be re-opened for SPED or Ex-SPED, the HCBS Case Manager only needs to complete the Add New Record to MMIS Eligibility File – SPED & Ex-SPED (SFN 676) and submit to Aging Services/HCBS. Neither the SPED Program Pool Data (SFN 1820) nor the Ex-SPED Program Pool Data (SFN 56) need to be completed.

For the SPED and Ex-SPED programs, complete the SFN 676 and forward to the Aging Services/HCBS Program Administration. The MMIS form should indicate the date the individual returned to services in the field “Date of Application” and "Re-Open" should be selected in the "Application Type" field.

4. Medicaid Waiver Recipients

For the Medicaid Waiver programs, the case manager must include the date of closure of the level of care screening on the SFN 474. Case managers must submit a SFN 474 to Aging Services/HCBS regardless of the reason for the closure i.e. death, going to a nursing home etc.

Submitting a “date of closure” is required in order for the Department to have accurate data when submitting federal reports.